No Surprises Act
Your rights to fair billing and transparency in healthcare costs
What is the No Surprises Act?
The No Surprises Act is a federal law that took effect on January 1, 2022, to protect patients from
unexpected medical bills. This law ensures that you receive a Good Faith Estimate of expected charges
before receiving services from out-of-network providers like myself. As an out-of-network mental health
provider, I am required to provide you with clear information about the cost of services before
treatment begins. This helps you make informed decisions about your care and avoid surprise bills.
Your Rights as a Patient
Under the No Surprises Act, you have the right to: • Receive a Good Faith Estimate of costs before
scheduling services or upon request • Understand what services will be provided and their associated
costs • Receive an itemized bill that matches the Good Faith Estimate (within reasonable limits) •
Dispute bills that exceed the Good Faith Estimate by $400 or more • Choose whether to use insurance or
pay out-of-pocket for services • Receive clear information about my network status with your insurance
plan
Good Faith Estimate
Before we begin working together, or upon your request, I will provide you with a Good Faith Estimate
that includes: • Expected costs for therapy sessions and any other services • Frequency of sessions
(weekly, bi-weekly, etc.) • Estimated duration of treatment (when applicable) • Breakdown of fees for
different service types (initial consultation, ongoing therapy, assessments) This estimate is based on
the information available at the time and may change if your treatment needs evolve. If significant
changes occur, I will provide you with an updated estimate. Please note that the actual cost may differ
from the estimate if your treatment needs change, the number of sessions varies from the original plan,
or additional services become necessary.
Billing & Payment Information
Session Fees: • Initial Consultation (60 minutes): [Fee provided in Good Faith Estimate] • Individual
Therapy Session (50 minutes): [Fee provided in Good Faith Estimate] • Psychological Assessment: [Fee
provided based on specific assessment type] Payment Options: • Payment is due at the time of service • I
accept cash, check, and major credit cards • For insurance reimbursement, I can provide documentation
(superbills) for you to submit to your insurance company Insurance: I am an out-of-network provider with
most insurance plans. This means: • You pay me directly for services • I provide documentation for you
to seek reimbursement from your insurance • Your insurance may cover a portion of out-of-network mental
health services • You are responsible for verifying your out-of-network benefits before beginning
treatment
Dispute Resolution Process
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to
dispute the bill through a federal dispute resolution process. To initiate a dispute: 1. Contact my
office first to discuss the bill and attempt to resolve the issue directly 2. If we cannot reach a
resolution, you may initiate the federal dispute resolution process 3. You must initiate the dispute
within 120 calendar days of receiving the bill 4. The dispute resolution process is administered by an
independent third party For more information about the dispute resolution process and your rights under
the No Surprises Act, please visit the official CMS resource page or contact my office with questions.
Learn More
For detailed information about your rights under the No Surprises Act, including standard consent forms and notices, please review the official CMS documentation.
View Official CMS DocumentQuestions About Billing or Your Rights?
If you have questions about the No Surprises Act, your Good Faith Estimate, or billing practices, please don't hesitate to reach out. I'm committed to transparency and want you to feel fully informed about the cost of your care.
Email•contact@hegertypsych.com
Phone•(414) 253-3256